Healthcare Provider Details

I. General information

NPI: 1497153332
Provider Name (Legal Business Name): MAURICIO A. VILLAVICENCIO MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MAURICIO ALEJANDRO VILLAVICENCIO THEODULOZ MD, MBA

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number264532
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number264532
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number1015
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: